MENCARI JURNAL BERDASARKAN PICO BOX

MELALUI SITUS PUBMED

Disusun Untuk Memenuhi Tugas Mata Kuliah Terapi Komplementer

Dosen Pengampu : Trimawati, A.Kep.,Ns., M.Kep.

Disusun Oleh :
Ela Lutfiatul U (012212013)

FAKULTAS KESEHATAN PROGRAM STUDI S1 KEPERAWATAN

UNIVERSITAS NGUDI WALUYO
TAHUN 2022
PICO box

P (populasi) : klien dengan kecemasan

I (Intervensi) : Latihan pernapasan

C (comparison) : -

O (Outcome) : Latihan pernapasan dapat meningkatkan farmakoterapi dan psikoterapi gangguan

kecemasan umum.

Analisa Jurnal

1. Tujuan
Penelitian ini bertujuan untuk mengetahui keefektifan Latihan nafas dan terapi tradisional pada
indeks pernapasan dan tingkat kecemasan pada pasien dengan gangguan kecemasan umum.
2. Methode
Metode yang di gunakan dalam penelitian ini adalah randomized double-blind clinical trial
3. Responden / klien
Sampel yang digunakan pada penelitian ini 41 pasien. 21 pasien pada kelompok terikat yang
akan mendapatkan pengobatan dan konseling rutin dan Latihan pernapasan. 20 pasien kelompok
control yang akan menerima pengobatan dan konseling rutin saja.
4. Waktu
Penelitian ini dilakukan selama 2 bulan, setiap 2 minggu pasien akan dipanggil untuk memantau
kepatuhan jadwal merekan.
5. Hasil
Hasil penelitian ini menunjukkan rasio FEV1/FVC meningkat secara signifikan pada kelompok
teriat pada periode tindak lanjut penelitian kedua setelah dua bulan. Kecemasan, FVC, FEV1,
Etco2, respirasi, dan denyut nadi dari waktu ke waktu cenderung ke arah hasil yang diinginkan
pada kelompok terikat dibandingkan pada kelompok kontrol, terutama setelah dua bulan, tetapi
perbedaan yang signifikan tidak terlihat
6. Kesimpulan
Kesimpulan pada penelitian ini adalah terdapat hasil yang signifikan antara pengarauh Latihan
ernapasan dan gangguan kecemasan. Latihan pernapasan menunjukkan bahwa dapat
meningkatkan farmakoterapi dan psikoterapi gangguan kecemasan umum.
 Langkah-langkah mencari jurnal dengan PICO-box melalui situs PubMed

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maka pada Langkah awal kita masukkan kata yang sebagai P (populasi / problem) yaitu
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 LAMPIRAN JURNAL

J. Phys. Ther. Sci. 34: 247–251, 2022

The Journal of Physical Therapy Science

Original Article

Effect of breathing exercises on respiratory

indices and anxiety level in individuals with
generalized anxiety disorder: a randomized
double-blind clinical trial
Alireza Maleki, PT, PhD candidate1, 2), Majid Ravanbakhsh, PhD1, 2)⁕, Mayam
Saadat1, 2), Mehdi Sayah Bargard3), Seyed Mahmoud Latifi4)
1)
Department of Physiotherapy, School of Rehabilitation, Ahvaz Jundishapur University of Medical
Sciences: Golestan St., Ahvaz, Iran
2)
Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical
Sciences, Iran
3)
School of Medicine Menopause Andropause Research Center, Ahvaz Jundishapur University of
Medical Sciences, Iran
4)
Diabetes Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical
Sciences, Iran

Abstract. [Purpose] The purpose of this study was to assess the efficacy of breathing exercises alongside
traditional therapy on respiratory indexes and the level of anxiety of generalized anxiety disorder patients.
[Participants and Methods] Forty-one patients were assigned a study group undergoing medication and routine
counselling plus breathing exercises (EXS), and a control group received medication and routine counselling
only (Non-EXS). Every two weeks, patients are called (weeks 2, 4, 6, and 8) to monitor their schedule
adherence. [Results] This study’s results showed FEV1/FVC ratio significantly increased in the EXS group in
the second study follow-up period after two months. Anxiety, FVC, FEV1, Etco2, respiration, and pulse rate
over time have tended towards desirable results in the exercise group than control groups, especially after
two months, but significant differences not seen. [Conclusion] This study’s findings indicated that breathing
exercises could improve generalized anxiety disorder’s pharmacotherapy and psychotherapy. Our data bring
up this hypothesis that longer follow up, increasing breathing period, and more exercising is associated with
higher outcome.

Key words: Generalized anxiety disorder, Breathing exercises, Respiratory

(This article was submitted Sep. 27, 2021, and was accepted Nov. 13, 2021)

INTRODUCTION
Generalized Anxiety Disorder (GAD) is a chronic and disabling disorder characterized by anxiety and
uncontrolled worrying in most of a person’s daily activities and family relationships 1). it is usually
associated with somatic complaints (tremor, palpitations, dizziness, nausea, muscle tension, etc.) and
psychic symptoms (difficulty concentrating, nervousness, sleep disturbances, etc.) for at least a six-
month period2). In some countries, the prevalence of this disorder was reported up to 6.2% and 3.7%
in medical care centers that reach about 89% with comorbidities. Females affected 1.5 to two times
more than males3).

Respiratory abnormalities in anxiety disorders were reported in patients with GAD. Hyperventilation
symptoms or disruption in pressure CO 2 (PCO2) level in large percentage of anxiety patients have
been shown4, 5). In this regard, breathing training was shown regardless of the type of method,
decreasing hyperventilation and subsequently reducing anxiety 6, 7). Buteyko breathing technique
(BBT) is one of the breathing exercises to achieve this. In this method, patients trained with

*Corresponding author. Majid Ravanbakhsh (E-mail: majidravanbakhsh@yahoo.com)

©2022 The Society of Physical Therapy Science. Published by IPEC Inc.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No
Derivatives (by-nc-nd) License. (CC-BY-NC-ND 4.0: https://creativecommons.org/licenses/by-nc-nd/4.0/)

reduced-volume breathing how consciously control their breath to inhibit the starting breath-relating
symptoms. In BBT, focusing on mouth breathing and upper chest breathing improves the
dysfunctional breathing in chronic hyperventilation which is seen in GAD8). It was indicated that BBT
has a positive effect on controlling breath rating and improves control and quality of life in asthma
patients9, 10). But there is a lack of the evidences to evaluate this mechanism in the treatment of GAD
patients.

Alongside the medications, psychotherapy like cognitive behavioral therapy is recommended to

increase the outcome of GAD treatment. In the meantime, it was demonstrated that hypocapnia,
one of the major hyperventilation symptoms, can reduce the result of cognitive-behavioral
therapy11). By breathing retraining, the treatment outcome will improve 12). There is a wide spectrum
of drugs are used to treat GAD, but there are several side effects that influence the quality of
treatment. Hence, there is a need for alternative or supplemental therapeutic approaches alongside
the traditional treatment to reduce the side effects. In recent years, there was an increasing interest
in evaluating the impact of breathing exercises on mental disorders. In the current clinical trial, we
investigate the impact of breathing exercises alongside traditional therapy on respiratory indices,
and the level of anxiety of patients to improve quality of life and reduction period of treatment.

PARTICIPANTS AND METHODS

The current survey is a double-blind randomized trial comparing the effect of breathing exercises
besides the medication and routine counseling versus the control group received medication and
routine counseling only. Patients were recruited to the department of Musculoskeletal Rehabilitation
Research Center in Ahvaz Golestan Hospital, Ahvaz, Iran, from November 2019 to December 2020.
The study was based on the approval of the Medical Ethics Committee of Jundishapur Ahvaz
University (Reference Number: IR.AJUMS.REC.1398.221) and registered at the Iranian Registry of
Clinical Trials (code IRCT20181017041374N1). Eligibility criteria required individuals to have received:
patients with age between 18–45 years, have a higher degree than a diploma, no abuse to drug and
alcohol, not participating in professional physical activity or sports professionally and earning the
necessary points from the Beck Activity Level questionnaire and Individuals with respiratory
hyperventilation pattern who scored 23 out of 64 in the evaluation by Nijmegen questionnaire.
Exclusion criteria were considered as the history of nervous-musculoskeletal disease or injury which
interrupt with the breathing, heart rate exceeds normal based on age, having a cardiovascular
disease based on self-reported individuals, the existence of any disruptions in the higher respiratory
tract, patients with a mental disorder such as major depression, panic and other psychiatry disorder,
and pregnant women. Furthermore, patients with excessive worry during the project, which can
disrupt the research process, were excluded too. There were no restrictions for gender and race. All
patients’ informed written consent was provided before study entry.

Patients were randomly assigned to the EXS group or Non-EXS group by using non-stratified different
block randomization. An independent statistician carried it out. For allocation concealment, index
cards were placed in opaque, sealed envelopes. A research assistant not involved in recruitment or
assessment opened them in ascending order after baseline assessment. The physiotherapist that
assessed patients have no information about the group assignment.

Medications were prescribed for all patients, and also all patients received psychiatric counseling via
all periods of treatment. Drug dosage was constant via the study, and the patients had to agree with
it. The EXS group was instructed by a trainer (certified in Buteyko procedure) with the following
plane: 1. beginning control pause, 2. Slow breathing, 3. Putting together CP and slow breathing. Each
session started and ended with the control pause. Patients instructed sit quietly, relax the body, slow
breath then gently close their nose, until they feel the first need to breathe, then release the nose
and take a breath. They advise to reduce breathing rate and extended pauses in daily activities. Nasal
over oral breathing was encouraged. In the slow breathing stage, patients were asked to place the
finger under the nose, after inhalation, breath out slowly on the finger that feel warm air, so they
concentrate on calming their breath to decrease the volume of warm air they feel 13). Moreover,
diaphragmatic breathing, which includes coordinating abdominal movements and breathing with
each other were trained too. Finally asked of patients carried out a combination of techniques and
conducted during daily activities. Respiratory exercises were done once a day for 15 to 20 min for at
least four days a week, for one month of home practice and followed by two months. Every two
weeks, patients are called (weeks 2, 4, 6, and 8) to monitor adherence to their schedule and be given
guidance and assistance if they encounter any problems. After one month, patients recurred to
evaluating their situation. All measures were collected at Baseline, after one month and a two-month
follow-up.

General Anxiety Disorder-7(GAD-7), and Beck anxiety inventory (BAI) were used to assess the self-
report measures of anxiety, and diagnosis of GAD, respectively. Nijmegen questionnaire (NQ) is used
to diagnose hyperventilation syndrome and the severity of dysfunctional breathing patterns.
Spiroanalyzer ST-95 (Fukuda Sangyo, Tokyo, Japan) was used to evaluating respiratory spirometry
indexes, including Forced Expiratory Volume in the First second (FEV1), Forced Vital Capacity (FVC),
and the ratio of FEV1/FVC (%). The concentration of respiratory indexes capnometry, including end
Tidal CO2, PaCO2, PaO2, heart rate, and breath rate, were assessed by a capnograph instrument
(Viamed Company-2500-s, UK). Outcome measurements were assessed in random order at baseline,
after one month and a two-month follow-up.

Descriptive statistics of qualitative and quantitative variables were shown as frequency (percentage)

and mean ± standard deviation (SD). Independent-samples t-test and Mann–Whitney U test were

used to test the difference among quantitative variables in the study groups (EXS group and Non-EXS

group). The χ2 test was used to test the difference of frequency J. Phys. Ther. Sci. Vol. 34, No. 4, 2022
distribution of qualitative variables like sex in the study groups. Besides, the normality of data was
assessed using ShapiroWilk test. Generalized estimating equations (GEE) were utilized to assess the
changes in quantitative outcome variables over the study time (Baseline, Month1, and Month2).
P<0.05 was regarded as a significant statistical difference. Data analysis was done using statistical
software SPSS version 22.0 for Windows. The sample size of this study was determined using
G*Power, Version 3.0.10, (Franz Faul et al., Universitat Kiel, Germany). 42 patients (21 per group)
were calculated with 80% power, effect size of 0.5 and type I error a=0.05

RESULTS
Seventy-three patients were recruited for this study. Forty-eight eligible patients who matched the
inclusion criteria were identified with GAD. 4 patients dropped out in the first period due to
interference with their job times, and three of them in boost sessions due to the incompletion of
treatment. Finally, 41 patients were included and analyzed (EXS=21, nonEXS=20). 68.2% (28) of all
patients were female, and 31.8% were male (Table 1). There were no differences between the two
groups for age, body mass index (BMI), height, weight, and duration of disease, which indicated the
studied groups were identical in terms of the characteristics of participants in the study (Table 1).

GEE analysis indicated that the clinical outcomes, including Nijmegen, BAI, and GAD7, after one and
two treatments further reduction in EXS group compared to Non-EXS group, significant differences
between two group were not observed (Table 2). Spirometry respiratory parameters, including FVC,
FEV1, and FEV1/FVC ratio after one and two treatments significantly increased in both groups. FVC
and FEV1 trend to increase especially after two months in EXS than Non-EXS group, but significant
differences not seen. Further analysis revealed that FEV1/FVC ratio increased significantly in the EXS
group in the second study follow-up period after two months (Table 2). Capnometry respiratory
parameters trend to increase especially after two months in EXS than Non-EXS group, but significant
differences not seen (Table 2).

DISCUSSION
GAD is a common anxiety disorder characterized by persistent worry, restlessness, increased heart
rate, hyperventilation, and trouble with concentration. It can occur at any age. The treatment of GAD
is one of the most important challenges worldwide, especially when it has some overlaps with panic
disorder. There are several well-known treatments for GAD, but sometimes prolonging the
treatment period affects the quality of treatment and has adversely impacted the psychotropic
aspect of patients, especially in young adults. Current approaches to the management of GAD are
based on pharmacotherapy and psychotherapy; hence, complementary therapies can improve the
progression of therapy. Breathing training is one of the complementary therapies shown to reduce
hyperventilation and its beneficial effects on respiratory tract diseases (i.e., asthma) and panic
disorder8). Breathing pattern with impact on the brain alters the signals between brain and body 14).
BBT is one of the essential methods shown to help control anxiety disorders and stress 15).
Hyperventilation is one of the main annoying events that frequently occur in GAD. To overcoming
this phenomenon, it was indicated that diaphragmatic breath is helpful. BBT involving different
aspects of breathing, directly affects decreasing CO 2 and increasing O2 delivery to the tissue. A
considerable amount of literature was published on the influence of breathing methods on the panic
disorder or the impact of BBT on respiratory disorder (i.e., asthma) 16), but there has been no detailed
investigation about the effect of breathing exercises on GAD. This paper shows the consequence of
breathing exercises on treatment outcomes compared to traditional therapy (medication and routine
counseling).

We analyzed whether a breathing exercises intervention in GAD might improve the clinical outcome
of treatment. Over the course of 2 months, patients completed once a day for 15 to 20 min. Our
analysis showed FEV1/FVC ratio significantly increased in EXS group in the follow-up period after two
months. In line with this result, Jerath et al. suggest breathing

Table 1. Baseline characteristics of the study participants

Non EXS (n=20) EXS (n=21)

Gender Female 11 (55%) 17 (80.95%)*

Male 9 (45%) 4 (19.05%)
Age (years) 32.60 ± 8.10 34.81 ± 5.85**
Height (cm) 171.85 ± 9.62 167.57 ± 7.85***
Weight (kg) 81.05 ± 15.43 77.76 ±
13.99***
BMI (kg/m2) 27.49 ± 4.97 27.82 ± 5.43***
Duration of illness (days) 761.75 ± 33.21 748.38 ± 37.57**

Group Variable

*χ2 test, **Independent-samples t-test, ***Mann-Whitney U test. p>0.05 in all of variables between
two groups.

EXS: exposure; Non-EXS: non-exposure; BMI: body mass index.

Table 2. Descriptive statistics of clinical outcomes over time in the exposure (EXS) and non- exposure (Non-EXS)
groups

Time points
Variables Groups
Baseline Month1 (Post intervention) Month2 (Follow up)
Nijmegen† EXS 37.76 ± 10.24 15.62 ± 3.99 11.14 ± 3.21
Non EXS 37.85 ± 9.22 16.80 ± 3.27 13.45 ± 3.19

BAI‡ EXS 40.90 ± 10.53 18.62 ± 3.37 13.24 ± 3.62

Non EXS 41.15 ± 10.42 18.25 ± 3.06 15.25 ± 3.13

GAD-7§ EXS 19.33 ± 1.91 7.38 ± 1.83 5.86 ± 1.91

Non EXS 19.15 ± 1.93 7.70 ± 1.69 5.90 ± 1.25

FVC (L) EXS 3.88 ± 1.09 4.14 ± 0.96 4.29 ± 0.91

Non EXS 4.49 ± 1.41 4.64 ± 1.32 4.69 ± 1.30
 FEV1 (L) EXS 2.82 ± 0.87 3.28 ± 0.72 3.89 ± 0.85
Non EXS 3.26 ± 0.92 3.84 ± 1.04 4.01 ± 1.11

FEV1/FVC (%) EXS 73.14 ± 12.52 79.72 ± 9.52 90.89 ± 6.59*

Non EXS 74.41 ± 13.45 83.60 ± 9.51 85.99 ± 8.30

ETCO2 (%) EXS 3.85 ± 0.80 4.90 ± 0.46 5.32 ± 0.49

Non EXS 3.87 ± 0.58 4.83 ± 0.37 5.16 ± 0.30

RR (breath/min) EXS 20.57 ± 2.86 16.71 ± 2.53 15.33 ± 1.83

Non EXS 21.20 ± 3.11 18.30 ± 3.77 16.80 ± 2.98

PR (beat/min) EXS 88.71 ± 11.18 76.24 ± 7.86 69.95 ± 7.61

Non EXS 91.60 ± 10.84 83.95 ± 11.72 78.10 ± 12.44

BAI: Beck anxiety inventory; GAD-7: Gad anxiety disorder; FVC: Forced Vital Capacity; FEV1: Forced Expiratory Vol ume
in First second; SPO 2: saturation of O2; RR: respiratory rate; PR: pulse rate; ETCO 2: end-tidal CO2; EXS: exposure; Non-
EXS: non-exposure.
†
0–64 points; 23 out of 64 hyperventilation; ‡0–63 points; 26–63 severe anxiety; §0–21 points; 15–21: severe anxiety.

techniques could be used as complementary intervention for anxiety disorder due to relationship
between respiration and emotions and the effect of respiration on autonomic system 17). FVC, and
FEV1 parameters, ETCO2, respiratory and pulse rate over time have tended towards desirable results
in the EXS group than Non-EXS groups. These results indicated that breathing exercises successfully
decreased symptoms associated with dysfunctional breathing patterns in GAD patients; however, the
associations were not significant differences. Short follow-up or insufficient exercise can explain the
lack of significance. Our data bring up this hypothesis that longer follow-up and more exercising is
associated with higher outcomes. Additional to the longer follow-up, another explanation for lack of
significance in respiratory parameters can be the point to low control pause or control pause lower
than 25 seconds; it was indicated that the more extended control pause session is accompanied with
greater impact11). This is in line with recent evidence that revealed that breathing techniques
alongside medications in the long period helps address anxiety disorder 18).
This study’s finding showed anxiety after one and two treatments decreased in both group; however,
there were tended towards desirable results in the exercise group. McPherson et al. in a pilot study
showed multimodal interventions focusing on self-care behaviors is superior on conventional
treatment in GAD patients. In this study, GAD patients receive acupuncture, massage, yogic
breathing exercises, nutrition counseling, and exercise. They reported reduction in anxiety in these
patients but this study had not control group 19). In another investigation that conducted to evaluate
the influence of BBT on physical activity and management of stress in athletes, it was revealed, BBT is
associated with decreased heart rate and anxiety; this is in accordance with our results that heart
rate decreases and patients had a better sense and more relaxation 11). These findings are consistent
with Sajadi et al.’s recent data, who reported that diaphragmatic breathing helps reduce anxiety in
women20). BAI is routinely used for GAD screening and evaluating treatment efficacy among
respiratory parameters. However, recently, BAI is accompanied by a high number of false positives it
can explain the lack of significance in ours 21).

Dysfunction in the respiratory tract or pulmonary disease is accompanied by anxiety disorder 22, 23). In
this regard, GAD patients indicated a delayed or reduction in attention peak (P3) compared to
normal participants24), which influences medication treatment outcome and accounts for one of the
main respiratory complications in GAD. Additional to P3, the lung dysfunction in GAD patients
manifests itself as a reduction in FEV1/FVC ratio 25), so the correction of breath pattern accelerates
the therapy progression. It is in agreement with our findings that BBT with increasing FEV1/FVC ratio
in the EXS group was successful in better managing disease. These results differ from Boaviagem et
al., who reported breathing exercising does not influence pregnant women’s anxiety 26). It might be
to, the secretion of more and additional hormones in pregnancy that may influence the outcomes.
This study had some limitations. There was control group with no intervention. Therefore, the effect
of time on the recovery could not be obtained. In addition, exercise period in this study was low,
more exercising with longer period suggest in future studies. It is not possible to blind patients or
therapists in this study due to the nature of J. Phys. Ther. Sci. Vol. 34, No. 4, 2022

the intervention. Finally, as most participants in the study were females and gender distribution was
not equal between groups that could limit the generalizability of the findings.

This study’s findings indicated that breathing exercises could improve the pharmacotherapy and
psychotherapy of GAD. In this issue, the breathing period and intensities one of the most important
factors considered in a later investigation. Moreover, evaluating the impact of breathing exercises in
a certain age of patients to reveal the interference of age is also recommended.

Funding
This study is part of the Ph.D thesis of Alireza Maleki and was supported by a grant from the Ahvaz
Jundishapur University of Medical Sciences (PhD thesis grant no: PHT-9812).

Conflicts of interest
None.

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